Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2023;13(2):e2023144 1 Scabies Affects Quality of Life in Correlation with Depression and Anxiety Sema Koç Yıldırım1, Neslihan Demirel Öğüt1, Ece Erbağcı1, Çağrı Öğüt2 1 Department of Dermatology and Venereology, Uşak University Training and Research Hospital, Uşak, Turkey 2 Department of Psychiatry, Uşak University Training and Research Hospital, Uşak, Turkey Key words: scabies, quality of life, Dermatology Life Quality Index, depression, anxiety Citation: Koç Yıldırım S, Demirel Öğüt N, Erbağcı E, Öğüt Ç. Scabies Affects Quality of Life in Correlation with Depression and Anxiety. Dermatol Pract Concept. 2023;13(2):e2023144. DOI: https://doi.org/10.5826/dpc.1302a144 Accepted: November 3, 2022; Published: April 2023 Copyright: ©2023 Koç Yıldırım et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Dr. Sema Koç Yıldırım; Uşak University Training and Research Hospital, Department of Dermatology and Venereology, Uşak, Turkey; Tel: +90 536 7371594; E-mail: semakocyildirim@gmail.com Introduction: Scabies is a highly contagious disease affects many people worldwide each year and a major public health problem. A small number of studies have shown that scabies causes impairment in the quality of life in adult patients. Objectives: The aims of this study are to assess the impact of scabies on adult patients quality of life (QoL) and evaluate the relationship between depression and anxiety levels and impairment in life quality. Methods: This cross-sectional study included adult patients diagnosed with scabies in our dermatol- ogy outpatient clinic. The effect of scabies on QoL was evaluated by Dermatology Life Quality Index (DLQI), and the levels of depression and anxiety were evaluated by Beck Depression Scale (BDS) and Beck Anxiety Scale (BAS). Results: Totally, 85 patients included to the study. QoL of 72.2% of the patients was moderate to extremely large affected. There was a positive correlation between the duration of the disease, the total DLQI score and the severity of the disease impact on QoL (rs= 0.287, P = 0.01 and rs=0.280, P = 0.008, respectively). A positive correlation was found between the number of treatments received and the total DLQI (rs= 0.223, P = 0.042). There was a positive correlation between BDS and BAS, and total DLQI score (rs=0.448 and P = 0.000; rs=0.456 and P = 0.000, respectively). Conclusions: Scabies has a moderate to severe effect on QoL. There was a positive correlation between impairment QoL and anxiety and depression scores. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2023;13(2):e2023144 Introduction Scabies is a contagious skin infestation caused by the mite Sarcoptes scabiei variant hominis. It affects approximately 455 million people worldwide each year and is still a ma- jor public health problem in many resource poor-urban and rural regions of developing world [1]. Recently, sca- bies outbreaks have been reported in many countries. It was also announced as the most common Neglected Tropical Diseases (NTDs) with skin manifestation according to the World Health Organization list of NTDs [2,3]. In a study from Turkey, it was found nearly 30-fold increase in the number of patients with the diagnoses of scabies compar- ing 2017 and 2019 and it was also detected that, approxi- mately 13% of patients were resistant to repetitive topical treatments [4]. Scabies often causes severe itching and patients suffered from social stigma, sleep disruption, difficulties in concen- tration and productivity [2,5]. It was reported that scabies was responsible for 0.21% of disability adjusted life years from all conditions studied by Global Burden of Disease 2015 worldwide [6]. Therefore, the morbidity of scabies may be related to both the degree of clinical pathology and emotional aspects of the disease. Further, scabies may re- duce the quality of life (QoL) of patients with the increasing incidence and treatment resistance. There are few reports in the literature evaluating QoL of adult patients with sca- bies [5,7-9]. To the best of our knowledge, there is no study evaluating the relationship between scabies and depression and anxiety. Objectives In our study, we aimed to investigate 1) the effects of the disease on QoL by Dermatology Life Quality Index (DLQI) and to evaluate the depression and anxiety scores through Beck Depression Scale (BDS) and Beck Anxiety Scale (BAS) in adult patients diagnosed with scabies 2) the relationship between the social and demographic characteristics of the patients and these measures, and 3) the relationship between DLQI and anxiety and depression scores. Methods Study Design This cross-sectional study included patients with scabies aged 18 years or older during the period between June 2021 and December 2021 in our dermatology outpatient clinics. Informed consent was obtained from all patients. The approval of the Institutional Review Board was re- ceived (IRB approval status [approval date and number: 20.05.2021/602.03.99]). Patients Demographic data of patients including age, gender, educa- tion status, marital status, time between onset of disease and diagnosis, previous treatment history for scabies, personal and familial psychiatric disease history were recorded. Ac- cording to the age, patients were classified as young adults (18-44 years), middle-aged persons (45-65 years) and aged persons (> 65 years). Educational levels of patients were classified according to the Turkish national education system such as literate, primary school graduate, secondary school graduate, high school graduate and university graduate. The diagnosis of scabies depended on the 2020 International Alliance for Control of Scabies (IACS) Consensus Criteria for the Diagnosis of Scabies [10]. Patients diagnosed with scabies according to level B (clinical scabies) and level C ( suspected scabies) by the dermatology specialist were in- cluded to the study. Patients who used 5% permethrin cream or lotion with an interval of 7-14 days or 12.5% sulfur ointment for 3 consecutive days were considered to have re- ceived appropriate treatment [11]. Each cycle of these treat- ments was considered a single time treatment. Individuals younger than 18 years of age, being pregnant, having crusted scabies and having personal psychiatric disease history were not included in the study. All patients were asked to complete the questionnaires, including DLQI, BDS and BAS. Questionnaires DLQI is comprised of 10 items focuses on 6 domains in- cluding symptoms and feelings, daily activities, leisure, work and school, personal relationships and treatment. The DLQI were scored on a 4-point Likert scale (0, “not at all”; 1, “a little”; 2, “a lot”; 3, “very much”), with the total score ranging from 0 to 30. The higher scores mean the more QoL impaired. During the analysis, scores were banded into five categories according to the severity of the disease impact on patient life as follows: 0-1, no effect; 2-5 small effect; 6-10, moderate effect; 11-20, very large effect and 21-30, extremely large effect. Also, a score of 1 or more for each domain was accepted as impairment in that domain. Turkish validity study of DLQI was con- ducted [12]. BDS is a 21-item self-report inventory. For each symptom category, there are four sentences; the subject endorses one of them according to his/her experience during the previous week. This form provides a four-point Likert-type measure- ment. Each item gets progressively increasing points between 0-3. A high total score indicates a high level of depression severity. The BDI was developed by Beck et al was adapted to the Turkish population by Hisli [13,14]. BAI is a 21-item self-report inventory. The items involve symptoms of anxiety. Subjects are asked how much they Original Article | Dermatol Pract Concept. 2023;13(2):e2023144 3 experienced each symptom during the previous week on a four-point Likert-type scale of 0–3. Higher total scores in- dicate higher levels of anxiety. BAI was developed by Beck et al and adapted to the Turkish population by Ulusoy et al. [15,16]. Statistical Analysis The statistical analysis was carried out using IBM SPSS Sta- tistics 28.0. Continuous data were given as mean ± standard deviation (SD) and median ± interquartile range [IQR]. Cat- egorical data were given as percentage. Pearson Chi-Square and Pearson Exact Chi-Square analyzes were performed in the analysis of the cross tables. Mann-Whitney or indepen- dent samples t tests were used for quantitative variables. The correlation analyses were performed using Spearman rank correlation coefficient (rs). For statistical significance, P < 0.05 was accepted as the criterion. Results Demographics A total of 85 patients with scabies were included in the study. Forty-one (48.2%) of the cases were female and 44 (51.8%) were male. The mean age ± SD of the study population was 34.07 ± 12.33 (17-66) years. According to the age catego- ries, most of the patients were young adults (76.5%), while 22.1% of the patients were middle-aged and 1.2% were aged. The median disease duration was 8 weeks (IQR 9). The median duration between the onset of disease symptoms and the time of diagnose was 6 weeks (IQR 4). Thirty of patients (35.3%) had received at least one of the appropriate treatment options including 5% permethrin cream or lotion and 12.5% sulfur ointment. Fourteen percent of patients had received one of the treatment options at least two or more times. The medications were prescribed by a dermatologist to 43.3% of the treated patients and the close contacts of 70% of the treated patients were also offered treatment. Only two patients had a familial history of psychiatric ill- ness. The demographic and social characteristics of patients shown in Table 1. DLQI Eighty-three of the patients had completed DLQI. The over- all mean DLQI score ± SD was 10.54 ± 6.17 (median 9.00). According to the severity of the scabies impact on QoL of 72.2% of the patients was moderate to extremely large af- fected. Banding of DLQI with the scores of the patients was shown in Table 2. The mean score ranged from 0.98 to 3.55 and the median score ranged from 1 to 3 in the individual domains (Figure 1). The domain with the highest impact on patients that ‘symptoms and feelings’ was impaired in all Table 1. Demographic and social features of patients. Number of patients, N (%) 85 (100) Gender, N (%) Female Male 41 (48.2) 44 (51.8) Age (year), mean ± SD 34.07 ± 12.33 Disease duration (weeks), median (IQR) 8 (9) Education, N (%) • Literate • Primary school graduate • Secondary school graduate • High school graduate • University graduate 2 (2.4) 21 (24.7) 21 (24.7) 24 (28.2) 17 (20) Number of patients received appropriate treatment 5% Permetrin cream/lotion N (%) 12.5 % Sulfur ointment N (%) 30 28 (93.3) 10 (33.3) Number of treatments, N (%) • single time • two times • three times • four times 18 (21.25 (5.9) 3 (3.5) 4 (4.7) IQ = interquartile range; SD =standard deviation. ‡. patients. The other domains that had the most impact on patients were ‘work and school’, ‘personal relationships’ and ‘daily activities’, respectively. The impairment of each do- main was demonstrated in Table 3. There was no statistically significant relationship be- tween total DLQI and gender, education status, marital sta- tus, having appropriate treatment and having any comorbid disease. The total DLQI score was higher in young adults and the difference was statistically significant (P = 0.06). A positive correlation was found between the duration of the disease, the total DLQI score and the effect severity (rs= 0.287, P = 0.01 and rs=0.280, P = 0.008, respectively). There was also a positive correlation between the num- ber of treatments received and the total DLQI (rs= 0.223, P = 0.042). The time between the onset of complaints and Table 2. Banding of the Dermatology Life Quality Index with the scores. Number of patients, N (%) Score Effect severity 1 (1.2) 0-1 No effect 22 (26.5) 2-5 Small effect 25 (30.1) 6-10 Moderate effect 28 (33.7) 11-20 Very large effect 7 (8.4) 21-30 Extremely large effect 4 Original Article | Dermatol Pract Concept. 2023;13(2):e2023144 disease duration and the number of treatments were higher in those who were with impairment in the ‘treatment’ do- main (question 10) than those who were not (P = 0.042 and P = 0.015, respectively). For other domains, there was no sig- nificant difference in disease duration, time to diagnose and the number of treatments between those with impairment and those who were not. BDS and BAS Seventy-five of patients completed BDS and BAS. The mean BDS score ± SD was 12.11 ± 9.52 and the mean BAS score ± SD was 8.81 ± 9.45. There was no statistically significant relationship between BDS and BAS with age, gender, edu- cation status, having appropriate treatment and having any comorbid disease. No correlation was found between the du- ration of the disease, time to diagnose, number of treatment, and BDS and BAS (Table 4). There was a positive correlation between BDS and BAS with total DLQI score (rs=0.448 and P = 0.000; rs=0.456 and P = 0.000, respectively). Also, we have compared the BDS and BAS scores of af- fected patients and non-affected patients for each DLQI do- main. Those who have impairment in the domain 2 (daily activities) and domain 4 (work and school) had significantly higher BDS and BAS scores than those without. The BDS scores of those with impairment in the domain 5 (personal the diagnosis was not effective on total DLQI score and the severity of the impact on QoL. The correlations related to total DLQI scores and the severity of the disease impact on life quality were shown in Table 4. There was no difference between the patients with im- pairment and without impairment for each domain in terms of gender, age, educational status, presence of any comorbid disease and having appropriate treatment. When we compare those with and without impairment in individual domains, the disease duration and the time to diagnosis was longer in those with impairment in ‘daily activities’ (question 3 and 4) than those without, and this difference was statistically sig- nificant (P = 0.016 and P = 0.019, respectively). Also, the Figure 1. Mean scores of the patients for each domain. Table 3. Impairment of each DLQI domain in patients with scabies. Domain DLQI questions Number of patients, N (%) 1. Symptoms and feelings 1,2 83 (100) 2. Daily activities 3,4 55 (66.2) 3. Leisure 5,6 49 (59.0) 4. Work and school 7 57 (68.6) 5. Personal relationships 8,9 55 (66.2) 6. Treatment 10 46 (55.4) Original Article | Dermatol Pract Concept. 2023;13(2):e2023144 5 ‘leisure’, ‘work and school’ and ‘daily activities’ was greater in males [9]. On the other hand, in a different study, the au- thors were not found any relationship between the gender and education similar to our study [5]. These differences may be related to the fact that the studies were conducted in dif- ferent geographical regions of the world and sociocultural differences. In studies, the effect of symptom duration on QoL was not generally mentioned, and only one study reported that those with a symptom duration of 8 weeks or longer tended to have more severe impairment on QoL [8]. In our study, the median disease duration was 8 weeks and we found a positive correlation between the duration of the disease, the total DLQI score and the effect severity. Recently, scabies outbreaks have been reported in many countries [17-20. In a study conducted in distinct geographic regions of Turkey, a 7-fold increase was found comparing 2017 and 2018, and a 30-fold increase was found and 2017 and 2019 [4]. Moreover, in recent years, treatment resistance of scabies has been remarkable, and this may be a cause of the prolonged disease duration [4,19–23]. In our study, 14% of patients had received one of the treatment options at least two or more times and we found a positive correlation be- tween the number of treatments received and the total DLQI. It is possible to say that treatment unresponsiveness nega- tively affects QoL. Relationships between some dermatological diseases such as psoriasis, vitiligo, atopic dermatitis, acne vulgaris, seborrheic dermatitis, hidradenitis suppurativa and chronic pruritus and depression and anxiety were evaluated in differ- ent studies [24-28]. However, to the best of our knowledge, no study has been conducted to evaluate the relationship between scabies and depression and anxiety. In a study eval- uated the depressiveness and anxiety of psoriasis patients, the mean BDS score was calculated as 9.36 ± 1.88 and the mean BAS score was found as 11.36 ± 1.79 [29]. In another study including the chronic urticaria patients, while the mean BDS score was 10.56 ± 7.90, the mean BAS was 14.28 ± 11.58 [30]. In our study the mean BDS score was 12.11 ± 9.52 and the mean BAS score was 8.81 ± 9.45. While BDS scores were comparable to these studies, the BAS scores in relationship) and domain 6 (treatment) had higher than those without. Also, the BAS scores of the patients with im- pairment in the domain 3 (leisure) were higher than without impairment. These findings were shown in Table 5. Conclusions To the best of our knowledge, this is the first study to evalu- ate the life quality of Turkish patients diagnosed with scabies and also the depression and anxiety scores and their relation- ship between DLQI scores in the literature. In the previous studies that investigated health-related quality of life, it was found that scabies had a small to mod- erate effect on life quality [3,5,7-9]. In our study, it was clearly found that scabies had considerable effect on quality of life of patients. According to the DLQI scores, the QoL of 72.2% of the patients was affected moderate to extremely large. The mean DLQI ± SD score of patients in our study was 10.54 ± 6.17. In a study from China it was reported 10.09 ± 5.96 similar to our study [5] . In another study, the mean score was reported as 3.1 but it was stated there was a positive correlation between the severity of the disease and the scores and, the mean score of adults with severe scabies was 7.8 [9]. In our study, the domains with the most impact on patients were ‘symptoms and feelings’, ‘work and school’, ‘personal relationships’ and ‘daily activities’, respectively. All of patients had impairment in the domain of ‘symptoms and feelings’ and the impairment percent of other domains were close to each other. In a study, it was reported that ‘symp- toms and feelings’, ‘work and school’ and ‘personal relation- ships’ had the most impact on patients [5]. In another study, the major domains affected in adults were ‘work’ and ‘feel- ings’ [7]. Our findings were comparable to these results in the literature. In our study, there was no difference between the gen- der and educational status, and the DLQI score but the total DLQI scores were higher in young adults (P = 0.06) also, most of the patients of our study population was the young adults (76.5%). In a study, it was reported that ‘feeling of shame’ significantly more often reported by female adults as compared with males[8]. In another study, the impact on Table 4. The Spearman rank correlation coefficients (rs) for the total DLQI scores, DLQI effect severity, BDS and BAS. Total DLQI DLQI severity BDS BAS rs P rs P rs P rs P Disease duration 0.280 0.010 0.287 0.008 0.201 0.084 0.05 0.963 Time to diagnosis 0.098 0.378 0.159 0.150 0.122 0.297 0.026 0.824 Number of treatments 0.223 0.042 0.203 0.066 0.095 0.417 0.07 0.551 BAS = Beck Anxiety Scale; BDS = Beck Depression Scale; DLQI = Dermatology Life Quality Index. 6 Original Article | Dermatol Pract Concept. 2023;13(2):e2023144 Ta b le 5 . T h e co m p ar is o n o f th e B D S an d B A S sc o re s o f p at ie n ts w it h a n d w it h o u t im p ai rm en t fo r ea ch D L Q I d o m ai n . D o m a in 2 D o m a in 3 D o m a in 4 D o m a in 5 D o m a in 6 A ff e ct e d N o n - a ff e ct e d P A ff e ct e d N o n - a ff e ct e d P A ff e ct e d N o n - a ff e ct e d P A ff e ct e d N o n - a ff e ct e d P A ff e ct e d N o n - a ff e ct e d P B D S sc o re , m ea n ± S D 1 4 .1 2 ± 9 .2 2 8 .3 1 ± 9 .0 6 0 .0 3 1 3 .4 4 ± 9 .3 2 1 0 .3 3 ± 9 .4 9 0 .0 5 1 1 4 .1 0 ± 9 .5 6 7 .9 6 ± 8 .5 6 0 .0 0 2 1 3 .7 7 ± 9 .6 0 9 .0 8 ± 9 .1 0 0 .0 1 7 1 3 .9 5 ± 9 .5 2 1 0 .0 0 ± 9 .4 6 0 .0 3 3 B A S sc o re , m ea n ± S D 1 0 .9 8 ± 9 .8 8 4 .4 8 ± 6 .8 5 0 .0 0 0 1 0 .1 9 ± 9 .3 1 5 .6 ± 7 .0 9 0 .0 0 1 9 .8 6 ± 9 .3 5 4 .9 1 ± 6 .0 5 0 .0 1 9 .5 2 ± 9 .4 1 5 .9 6 ± 6 .7 7 0 .0 8 2 9 .6 5 ± 9 .6 1 6 .6 7 ± 7 .3 1 0 .0 6 B A S = B ec k A n x ie ty S ca le ; B D S = B ec k D ep re ss io n S ca le ; D L Q I = D er m at o lo gy L if e Q u al it y In d ex ; SD = s ta n d ar d d ev ia ti o n . Original Article | Dermatol Pract Concept. 2023;13(2):e2023144 7 6. Karimkhani C, Colombara D v., Drucker AM, et al. The global burden of scabies: a cross-sectional analysis from the Global Burden of Disease Study 2015. Lancet Infect Dis. 2017;17(12): 1247-1254. doi:10.1016/S1473-3099(17)30483-8 7. Ashok Nair PA, Vora RV, Jivani NB, Gandhi SS. A Study of Clinical Profile and Quality of Life in Patients with Scabies at a Rural Ter- tiary Care Centre. J Clin Diagn Res. 2016;10(10):WC01-WC05. doi:10.7860/JCDR/2016/20938.8703 8. Worth C, Heukelbach J, Fengler G, Walter B, Liesenfeld O, Feld- meier H. Impaired quality of life in adults and children with sca- bies from an impoverished community in Brazil. Int J Dermatol. 2012;51(3):275-282. doi:10.1111/J.1365-4632.2011.05017.X 9. Lake SJ, Engelman D, Sokana O, et al. Health-related quality of life impact of scabies in the Solomon Islands. Trans R Soc Trop Med Hyg. 2022;116(2):148-156. doi:10.1093/TRSTMH /TRAB096 10. Engelman D, Yoshizumi J, Hay RJ, et al. The 2020 International Alliance for the Control of Scabies Consensus Criteria for the Diagnosis of Scabies. Br J Dermatol. 2020;183(5):808-820. doi:10.1111/BJD.18943 11. Salavastru CM, Chosidow O, Boffa MJ, Janier M, Tiplica GS. Eu- ropean guideline for the management of scabies. J Eur Acad Der- matol Venereol. 2017;31(8):1248-1253. doi:10.1111/JDV.14351 12. Öztürkcan S, Ermertcan AT, Eser E, Turhan Şahin M. Cross validation of the Turkish version of dermatology life quality index. Int J Dermatol. 2006;45(11):1300-1307. doi:10.1111 /J.1365-4632.2006.02881.X 13. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4(6):561-571. doi:10.1001/ARCHPSYC.1961.01710120031004 14. Hisli N. A study on the validity of Beck depression inventory. J Psychol (Psikoloji Dergisi) . 1988;6:118-122. 15. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measur- ing clinical anxiety: psychometric properties. J Consult Clin Psy- chol. 1988;56(6):893-897. doi:10.1037//0022-006X.56.6.893 16. Ulusoy M, Hisli-Sahin N, Erkmen H. Turkish version of the Beck Anxiety Inventory: psychometric properties. Journal of cognitive psychotherapy . 1998;12(2):163-undefined. 17. Redondo-Bravo L, Fernandez-Martinez B, Gómez- Barroso  D, et al. Scabies in Spain? A comprehensive epidemiological picture. PLoS One. 2021;16(11). doi:10.1371/JOURNAL. PONE.0258780 18. Lugović-Mihić L. The increase in Croatia’s scabies incidence: How did refugees and traveling contribute? Travel Med Infect Dis. 2019;29:74. doi:10.1016/J.TMAID.2019.02.002 19. Sunderkötter C, Aebischer A, Neufeld M, et al. Increase of sca- bies in Germany and development of resistant mites? Evidence and consequences. J Dtsch Dermatol Ges. 2019;17(1):15-23. doi:10.1111/DDG.13706 20. Turan Ç, Metin N, Utlu Z. Epidemiological Evaluation of Scabies Cases Encountered in the Last Three Years as a Tertiary Health Center. Turkiye Parazitol Derg. 2020;44(2):77-82. doi:10.4274 /TPD.GALENOS.2020.6796 21. Khalil S, Abbas O, Kibbi AG, Kurban M. Scabies in the age of increasing drug resistance. PLoS Negl Trop Dis. 2017;11(11). doi:10.1371/JOURNAL.PNTD.0005920 22. de Sainte Marie B, Mallet S, Gaudy-Marqueste C, et al. [Therapeutic failure in scabies: An observational study]. Ann Dermatol Venereol. 2016;143(1):9-15. doi:10.1016/J .ANNDER.2015.10.588 our study were lower. We did not find any correlation be- tween the duration of the disease and the number of treat- ment with BDS and BAS but we found a positive correlation between BDS and BAS with total DLQI. Nearly, all of pa- tients with impairment in each DLQI domain had higher scores of BAS and BDS except for BDS in domain 3 and for BAS in domain 5 and 6. These findings may be due to the chronicity of the pruritus, given the mean disease duration of patients in our study. It was demonstrated that chronic pru- ritus were associated with depression and anxiety [26,31]. These findings made us think that scabies, which affects QoL negatively like other chronic dermatologic diseases, may also have negative effects on depressiveness and anxiety, and may have effects beyond being a contagious skin disease. The limitations of our study are the relatively small num- ber of patients, lack of a control group, being not grouped the patients according to the clinical severity of scabies. Also, we did not follow up the patients after the treatment response and could not compared the DLQI, BDS and BAS before and after treatment. As a conclusion, scabies is a common dermatological problem in our daily routines and the factors such as the disease duration, the necessity of repeating treatment pro- tocols, itching severity and contagiousness may complicate the management of the disease. 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